Increased Intraocular Pressure after Extensive Conjunctival Removal: A Case Report

A 50-year-old woman, who had undergone extensive removal of conjunctiva on the right eye for cosmetic purposes at a local clinic 8 months prior to presentation, was referred for uncontrolled intraocular pressure (IOP) elevation (up to 38 mmHg) despite maximal medical treatment. The superior and inferior conjunctival and episcleral vessels were severely engorged and the nasal and temporal bulbar conjunctival areas were covered with an avascular epithelium. Gonioscopic examination revealed an open angle with Schlemm's canal filled with blood to 360 degrees in the right eye. Brain and orbital magnetic resonance imaging and angiography results were normal. With the maximum tolerable anti-glaucoma medications, the IOP gradually decreased to 25 mmHg over 4 months of treatment. Extensive removal of conjunctiva and Tenon's capsule, leaving bare sclera, may lead to an elevation of the episcleral venous pressure because intrascleral and episcleral veins may no longer drain properly due to a lack of connection to Tenon's capsule and the conjunctival vasculature. This rare case suggests one possible mechanism of secondary glaucoma following ocular surgery.